[bloga.epidemiologica]

[bloga.epidemiologica] is an exploration and conversation about how we think about epidemiology: put simply, the epistemology of epidemiology. I am reminded persistently that the world is becoming smaller; yet, it is changing more quickly than ever before. As it shrinks and adjusts, following an unknown, not-necessarily Newtonian, possibly Einsteinian algorithm, we must counter with updated theory and explorations that move the field of epidemiology beyond traditional methodology and theory.

29 October 2014

I
found this out in the same way I learn about all too many things. Not by
reading the New York Times, although I do, and I did find his obituary there;
but rather in a friend’s Facebook status.

I
am not a poet – not a published one, at least. I was an upstart, a somewhat
overly self-confident English minor at a small college in Virginia. That was in 1982 – or was it 1981? – when
I met Galway Kinnell.

I
was the sort of young woman who, at age 19-ish, was wallowing happily in Shakespeare,
modern poetry, writing, medieval history, Guinevere, Civil War battles, modern
dance, and Bach.

I
was part of the happy, smart, slightly self-absorbed and rather lucky band of
students assigned to pick up the poet who was coming to read. Galway Kinnell.
We read his work in class and I proudly owned his newest compilation, Mortal Acts, Mortal Words (published just a year or two before in 1980).

His
reading was a holy event. We listened, rapt. When Kinnell read, it was always
in a deep voice. He delivered from memory, even the longest of his poems:

In late winter

I sometimes glimpse bits of stream

coming up from

some fault in the old snow

and bend close and see it is lung-colored

and put down my nose

and know

the chilly, enduring odor of bear.

I take a wolf’s rib and whittle

it sharp at both ends

and coil it up

and freeze it in blubber and place it out

on the fairway of the bears.

And when it has vanished

I move out on the bear tracks,

roaming in circles

until I come to the first, tentative, dark

splash on the earth.

[The opening lines of “The Bear,” from Body Rags, first published in 1965]

That
evening we had dinner with this celebrated man and the next day that lucky few
of us were invited to meet with him. I can remember the classroom and the
window. Perhaps it was autumn. Perhaps not. We offered up short critiques of one
of his poems and he commented on some of our work. I asked him about one of his
nature poems – I don’t remember which, possibly “Blackberry Eating”, or
“Kissing the Toad.” I remember watching every move on his face as he pulled out
and read my little poem. Where my professor had been somewhat critical, Kinnell
defended my work. As I look back, it was clearly a rather trite piece – much
what one might expect from a young woman in my place and time.But, he defended it. He noticed the best bits
– the words that worked – and he quietly advised me on how I could make it better.

He
signed my book that afternoon “To Anne, my best explicator and critic. Galway
Kinnell.” I glowed.

Needless
to say I treasured that little book. I don’t have it anymore. I do have a
signed copy, but not the same one. A couple of years after his reading, my
roommate borrowed it and didn’t return it or maybe spilled coffee on it. I don’t
recall. I suspect she lost it. When she heard of my distress at losing a
favorite book, she mailed him a fresh copy with a long letter of explanation –
presumably in her flowery, almost Victorian handwriting – and asked him to
re-sign it for me.

It
came back to me, by post, but not quite the same. My roommate must have
thought I wouldn’t notice that the signature was a little bit different and
that it included my last name, slightly misspelled: “To Anne Baeber, my best explicator
and critic and faithful friend. Galway Kinnell.” Now, when I see it, I replay
my memories, but am a little ashamed by the misspelling that was my roommate's fault, not his, and I wish I could remember the glosses I made in the margins
in that long ago time when I was so sure about everything.

On
my bookshelf here in Iowa I have several of his books, all well-read, some worn and handled, all aged; including one with a recording that I may never have listened to – I do not
want the memory of his voice ruined by hearing it burned onto a CD. I hear it
in my head now, again, when I read about his children, Maud and Fergus, coming
home with snakes crawling from their pockets; about blackberries in September;
and bear blood.

25 October 2014

Focus on Africa, not
Dallas. Care more about the new case in Mali than the case in New York. A lot
more.

Professor Nancy Glass of
the Johns Hopkins University School of Nursing is leading a team from Hopkins Nursing and the Johns Hopkins Bloomberg School of Public Health and the Democratic Republic of the Congo (DRC) to
document existing outbreak protocols that have successfully squelched ebola fires in the Congo
for over 40 years. (As an aside, the Congo has quietly dealt with its own outbreak of a different strain of ebola, reporting no new cases since 4 October.) Problem is, these protocols are not documented in writing, but
rather imprinted in the country's medical and public health oral culture. Professor Glass' team is documenting these protocols and adapting them for use in west Africa. This work could prove vital to handling
an unexpected emergence of ebola in West Africa.

An excellent example
is The Gambia. Despite its proximity to ebola-affected countries in the region, there has not been a single documented case – and, what’s more – I am
told by a reliable source that there are no ‘hidden cases.’ Now that’s some
really big news.

The Gambian Ministry of Health is using
traditional drama in villagesto educate about ebola.
Photo: Dr. Bakary Sonko

Looking closely at
the map (and with a little assistance from Google Maps) shows that the distance from Boffa, Guinea - one of the outbreak sites closest to the Gambia - is about 1000 km. That’s a respectable distance, but it is far less (about 500 km) “as the crow
flies” or, more aptly, as a person can walk. While much attention had been
given to flights in and out of west Africa, it is safe to say that the vast
majority of those at highest risk for ebola are too poor to buy a plane ticket.

African borders are
notoriously porous. In west Africa, tribal and clan boundaries transcend
national boundaries, which were imposed based on the territorial claims of European
colonial powers. Families visit frequently across the many, many
kilometers of boundary land. These borders are simply
not practical – or necessary – to guard.

The Gambian Ministry
of Health has been working tirelessly using time-honored, basic public health
prevention programs, since March 2014. To date, they remain ebola-free.

How have they done
it?

Mr. Amadou Jallow, of the Gambian MOH/University
of the Gambia, leading a village sensitization session.
Photo: AW Jallow

It’s simple – basic
public health. First, they have increased surveillance. By this, I don’t mean
that they have healthcare workers going door-to-door looking for cases
(although that can be necessary), but they have taken a step back and trained
volunteers, children in schools, and individuals in communities to learn the
signs and symptoms and to know how to report a suspected case. In the Gambia,
it’s simple: phone 1025. Almost everyone has access in some way to a mobile
phone. There are many calls everyday – none have resulted in cases, but it
indicates that people are looking and that this quick, simple system has
potential.

Training, also known
as “sensitization” programs, have been stepped up. MOH staff, such as Mr. Amadou
Jallow and his many colleagues, have conducted numerous meetings with thousands
of villagers, school children and teachers, Red Cross and other volunteers, and
healthcare workers. In addition to meetings, the MOH has sponsored traditional
village dramas portraying ebola prevention and surveillance.

Posters and educational material like this
help spread the word about hand washing and
other simple prevention measures

A second important
effort has been to screen arriving passengers at the airport in Banjul.
Currently, medics screen arrivals for fever and take a medical history. While this
method is imperfect – anyone with a low-grade fever can take a
paracetamol/acetaminophen and get past the screening – it is a good method of
screening those who are highly symptomatic. Moreover, by collecting data on
arrivals, the MOH can track them in the coming weeks if they develop symptoms.
In a small country like the Gambia, every step helps.

I do not know
exactly what measures are being taken in other neighboring countries, like
Mali, Senegal (both of which have had one case), Guinea-Bissou, Côte d'Ivoire, Bukina Faso, and others. It would make
sense for all of these countries to adopt (and adapt, as applicable) the Gambia’s
practices.To this extent, it will be important for the Gambia to continue to document its
work in written protocols, photographs, and to be able to export these methods
to other high-risk countries. It would also be smart for the rest of the world
to observe the wisdom and sanity with which the Gambia is facing a potentially deadly
outbreak.

18 October 2014

As I type this, I am sitting in an airport cafe. The waiter just loudly announced that there are two ebola cases in Virginia. I have no idea if that is true or not. Either way, his tone of voice speaks volumes.

I read this week that in a recent US poll, over 50% of Americans are concerned that there will be a serious ebola outbreak
in the US. Nearly 60% think we should ban flights from Sierra Leone, Liberia, and Guinea. I don’t know about the subtleties of this poll – that is, are they simply
worried that there might be a few cases? That the word “concern” may have
varied interpretations (as in “sure, I’m concerned, but not really worried”
versus “I’m seriously concerned and starting to panic.”) Are they apoplectic
that they might die? Are Europeans equally panicked? I don’t know.

I do know that we have
24-hour news to blame for this panic.

The 24-hour news circus has whipped people up into a frenzy. And why not? It’s a good story. A scary
virus with seriously icky symptoms, a few thousand cases (albeit, all in west Africa),
and an innocent viewership (hey, not everyone is trained in epidemiology or
risk assessment). Even the most responsible of news organizations – and here I
am thinking of National Public Radio, PBS NewsHour, the New York Times,
etc.) cover the ebola outbreak on a daily basis. It has to be said that NPR and
PBS have been particularly responsible in reporting facts and not falling for
the temptation to sensationalize.

People are going nuts about an imported case and two transmissions in Dallas while thousands are dying in Africa. Thank you, cable news.

Let’s admit it. Ebola is ugly
and frightening. Once infected, people can become violently ill and die
following internal hemorrhage and ‘bleeding out’ through the eyes and other
orifices. But is this the epidemic that will kill millions worldwide? I doubt it. But, it will cause
excess deaths if people panic.

I am scared of fear. Fear
causes people to behave in irrational ways. They may take to the streets, they
may harm themselves or their neighbors if there is a treatment shortage, they
may cause political unrest, they are already becoming paranoid about government;
the list goes on.

Someone asks me almost every
day if I am worried. No, I am not overly worried, but I am very concerned for
the lives of people in Sierra Leone, Liberia, and Guinea. I am saddened that
these countries do not have a health infrastructure that can respond to an
outbreak or natural disaster and heartbroken when I see pictures of suffering people.
I am worried that people will continue to hide from doctors because they are
afraid to go to one of the many tent hospitals set up to treat patients; I am
worried that they will rebel when they don’t receive adequate treatment or
become paranoid about the motives of governments or healthcare workers.

For now, let’s stay calm. Let’s
be rational.

In the coming days, I am
going to post my own thoughts about this epidemic and other health risks. I
want to start an epidemic of rational discussion about what ebola is (and isn’t),
what other viruses we should be concerned about, and how we are managing the
outbreak in Africa. Stay tuned.

02 June 2014

Guest blogger Cristina Pérez Rubio is a 2014 graduate of James Madison University. In her own words, she is "A future nurse trying to find my purpose and way. The world gives us so many reasons to hate it, despise it, and give up on it. I don't know why, but I am still on a quest to find the good. I can't be alone in this. I love my dog, art, music, kids and babies, nursing, and anything inspiring."

While most people went to the beach or on a cruise to party hardy, I decided to spend my spring break doing volunteer work in Boston, MA. I signed up for the week-long trip through James Madison University's alternative spring break program and was thrilled to spend time at a homeless shelter making a difference. I, along with 8 other JMU students and 1 faculty member, embarked on the 9 hour drive to Boston early Saturday morning (March 8). You can imagine how uncomfortable the journey was since the 10 of us were packed into a JMU service vehicle, you know, one of those big white vans with four rows of seats. The drive up was fun, though, because we started to bond and get to know each other.

We stayed in Cambridge at a church right off of Harvard's campus. Within this church there was a nursery/day care, located on the third floor of the building, and a homeless shelter in the basement. The homeless shelter was operated by Harvard students who would volunteer to spend an entire night, every night, cooking meals and offering the available bunks to the homeless in the area. We slept in sleeping bags on the floor of the nursery/day care classrooms on the third floor. When it came to meals, we shared the kitchen with the Harvard kids in order to prepare our "asb family dinners".

Our mission on this trip was to volunteer at a homeless shelter in Boston, which was just a T (metro) ride away from our home away from home in Cambridge. The New England Center for Homeless Veterans (NECHV for short) is a shelter that specializes in offering men and women from the armed forces a place to stay and rebuild their lives. The majority of the veterans at NECHV suffer from some type mental illness, most commonly PTSD. While each veteran's story is different, the majority of them turned to alcohol or drugs to deal with the undiagnosed mental illnesses. One way or another, these individuals found themselves homeless and suffering.

NECHV is a unique combination of a homeless shelter and a detox program. It does not just offer a roof over their heads, it helps give the veterans the tools to go back into society as working "normal" individuals. While veterans do not have to comply with the rules, the shelter demands full sobriety of its residents as well as constant meetings with housing counselors who help them search for housing. The shelter also offers classes for the vets to take to get certified as bus drivers, security officers, mechanics, etc. NECHV uses a multifaceted approach to helping the vets better their lives.So where did we JMU dukes come in?...Sun 3/9 9AMWe showed up at the shelter early Sunday morning ready for orientation at the center. We were told that we would be assigned to go through the storage rooms in the shelter's basement. Here, they stored all sorts of things that they would sell at the shelter's store. This "store" was for the veterans to pick up anything they needed from toiletries to new interview-appropriate clothes, jackets, underwear, etc. We would have the chance to sit and talk with the vets at lunch, because the shelter was offering us free daily lunches. I, personally, was offered the opportunity to volunteer upstairs alongside the nurse, instead of downstairs in the storage rooms. Since I want to be a nurse, this was a unique opportunity for me to interact with a current nurse, as well as the vets, and to see how things were run at the shelter from a medical point of view.Mon 3/10 8AMMonday morning we commuted into Boston via the T and began to work. While my fellow asb-ers went downstairs to organize things, I sat outside Irene the nurse's office, excitedly waiting to meet her. 20 minutes passed and she finally showed up visibly out of breath and in a hurry. "Sorry I'm late! I had to run up and see some sick vets. I think the norovirus is going around. I had 7 confirmed cases today."...........um WHAT?! Don't get me wrong, I didn't show any visible signs of distress, but holy shit was I freaking out internally when she said that. I had flashbacks to the entry I made for this very blog about the cruise ships and the norovirus outbreaks. *gulp* I swallowed hard, reached for her desk-size hand sanitizer, smiled, and asked her what we had planned for the day.The day went on, I was learning so much and having fun. I reconnected with the other volunteers at lunch when we all buddied up to sit with the vets. I met two ex army medics who told me stories of combat and ER shifts. The first day at NECHV was going pretty well!

Mon 3/10 2:30PMAt the end of the day, all 10 of us to the T back to Cambridge while discussing that night's plan for dinner. While on the T, Carter, a junior poli sci major, suddenly gripped her stomach and confessed she felt nauseous. "DEAR GOD IT'S HAPPENING" was my instant thought. Of course, I didn't say that. "Carter you might have the norovirus," I said calmly as I noted her ashen sweaty face. "The what-?!" everyone asked. I, along with another future nursing student, described the symptoms to everyone and I explained how Irene had mentioned to me that there were confirmed cases at the center. "Oh there's no way! Shut up, stop trying to freak us out, Cristina!" ...no one believed me and I secretly hoped I was wrong in my suspicion...Mon 3/10 6:00PMThere I was, with a bucket of clorox bleach and yellow gloves up to my elbows, cleaning up the chunks of Carter's vomit in the sink. She didn't make it in time to the bathroom and no one else on the trip wanted to clean it except for me and Alexis (the senior future nursing student I mentioned earlier). Carter was en route to the emergency room because she was blacking out from dehydration. We had already stopped by a local CVS and bought her some Pepto, Gatorade, and saltine crackers, but she couldn't keep any of it down. She needed to get IV fluids stat. You better believe everyone's hands were raw from scrubbing them after having witness Carter's misfortune. Before she left, I slipped into the bathroom to see how she was doing. The poor thing was on the toilet, diarrhea and all, with her head in the trashcan, vomiting.Other volunteers were still going through the "what ifs" of the situation and how the ER doctors would "surely diagnose it as food poisoning. There was no way it could've been the norovirus." After 7 hours in the ER, Carter came back with the diagnosis... norovirus. There I was panicking yet throwing a party in my mind. My suspicion was right. I used my health education and common sense to prematurely diagnose her and I was validated by the ER team. On the other hand, if anyone was exposed to the super bug it was me and my fellow volunteers. Still, I held on to a naive sense of "it won't happen to me" I'm the nurse in this situation. Alexis and I were the ones calming everyone down. We couldn't get sick... there was no way.

Tues 3/11 8:00 AM7 of the 10 of us showed up to the shelter Tuesday morning. Carter was quarantined into her own bedroom (aka a separate classroom within the nursery), and the other two volunteers who accompanied her to the ER were asleep. It had been a very long night. I met with Irene as scheduled and she explained how she had to email the Massachusetts Department of Health because they had a full-blown outbreak of the norovirus. "Funny story.." I told her about Carter and how she got sick. Irene had me help her make flyers for the veterans about the norovirus and how hygiene was a huge preventative and protective factor. The day went on as planned, including a couple hundred trips to the bathroom to wash my hands.Tues 3/11 6:00 PMI was getting used to the routine we had going and found that I enjoyed sharing the kitchen with the Harvard kids to make dinner for our group. That night we decided on having a group "brinner"... breakfast for dinner. I made everyone pancakes while other people made omelets and bacon. I even made Carter her chicken broth and bonded with some Harvard students who were nonchalantly describing how they were going to med school next year (cue the eye roll). The dinner was delicious and I enjoyed three of the hearty pancakes I had worked so hard on. I remember thinking I had overeaten and that I was suffering from a major case of food baby. I also had a terrible headache for which I had to take four 200mg ibuprofens. I also ended up chugging almost 1 liter of water because I thought the headache may have been a result of dehydration. The headache went away, but I still felt uncomfortably full and bloated.Wed 3/12 2:30 AMWe went to bed late Tuesday night because we had spent so much time talking about our day's events. We were excited Carter was feeling better and she was telling us all about what she had gone through. I usually sleep through the night and only wake up to pee (since my bladder is the size of an acorn), so I was surprised to wake up at 2:30 feeling burpy and a sense of gurgling in my gut. This is way too much information, but the only reason I woke up was because I had to fart, and for some reason I had the feeling that this was one of those farts you just know you shouldn't trust. So off to the bathroom I went hoping and praying that my worst fears were not about to come true....

Wed 3/12 4:00 AMThere I was on the floor of the bathroom, convinced I was dying a slow death. I had the norovirus. How was I so sure? Somewhere between violently and projectile vomiting and diarrhea-ing at the exact same time I knew. Let me just make this clear... anyone who dares say they have the norobug but are able to get up, vomit, and later, have a bowel movement, is WRONG. The norovirus makes you expel copious amounts of liquid from both ends at the same time. I was literally shitting my insides out, legs shaking and dangling because I was too short to touch the floor and the toilet was high off of the ground, while throwing up pure bile and probably the lining of my intestines. In between dry-heaving and flushing the toilet I found myself so desperate for help and relief, that I was praying to any deity out there willing to listen. I was weak and out of it.I cleaned off all of the surfaces, washed my hands profusely and left the bathroom. I found myself in the hallway with Steven, the JMU employee and our chaperone on the trip. Listen, I know I was not looking gorgeous at that moment, but boy did he look like crap. "Are you...?" "YES" I cut him off. "Me too." He said. Another volunteer had woken up and realized what was happening and grabbed our stuff. Carter was up as well. Steven and I were now excommunicated from the group and put into our own quarantined room. In less than 36 hours, our group went from 1 sick person to 3.Wed 3/12 11:00 AMSteven and I stayed behind and did not go back to the shelter. Quite frankly we were so dehydrated we probably should have gone to the hospital for IVs too, but instead we slept it off. Steven kept throwing up while I only had diarrhea. We would both wake up moaning in pain, curled up in the fetal position. It felt like I had ninjas in my abdomen attacking my intestines. From the constant fits of vomiting and diarrhea my insides were beyond empty and I was feeling the pain.Steven and I got a call from the group which had gone in to volunteer that morning and they reported that two more people from our team were feeling ill. Surprise, surprise...

Wed 3/12 11:00 AMSteven and I stayed behind and did not go back to the shelter. Quite frankly we were so dehydrated we probably should have gone to the hospital for IVs too, but instead we slept it off. Steven kept throwing up while I only had diarrhea. We would both wake up moaning in pain, curled up in the fetal position. It felt like I had ninjas in my abdomen attacking my intestines. From the constant fits of vomiting and diarrhea my insides were beyond empty and I was feeling the pain.Steven and I got a call from the group which had gone in to volunteer that morning and they reported that two more people from our team were feeling ill. Surprise, surprise...Wed 3/12 5:00 PMSince Steven and I were in and out of sleep (especially Steven because he had a low grade fever) we didn't really notice when Alexis, my fellow senior bio major and future nurse, snuck into the room after having been excommunicated from the group. Alexis got sick while at the shelter and suffered through what must have been an agonizing metro trip back to Cambridge. Steven and I welcomed her into our "sick room" and filled her in on what the next several hours were going to be like for her.Wed 3/12 11:30 PMAt this point, Alexis' violent vomiting fits had subsided and she finally fell asleep. I woke up at this time and was surprised to see a body within a sleeping bag, contorted in the fetal position, lying next to me on the floor. There was moaning coming from within the sleeping bag and blonde hair sticking out of it. Caroline, a sophomore poli sci major, was the fifth person from our trip to appear in our sick room and come down with the norovirus.

Thurs 3/13 9:00 AMI woke up feeling much better. It had been a little over 24 hours since I initially gotten sick and the vomiting stopped. The good news was that the norovirus ends almost as quickly as it comes. It's probably the sickest I have ever been, but it went by quickly. At this point in the trip I had only ingested two cans of gatorade and a slice of white bread. The JMU asb team back in Harrisonburg was in contact with our group in Boston. They told us not to go back to the shelter and that it would be best for us to leave. They tracked down an extra van to rent from Enterprise which was dubbed the "sick van."Thurs 3/13 2:30 PMThe healthy people from our group helped us sick folk out by making trips to CVS for us. They bought us Depends (yes, the adult diapers), gatorade, white bread, face masks, gloves, and trash bags. Around 2:30pm, we evacuated Cambridge and left for home. The healthy and sick vans caravanned home and made it back to Harrisonburg by 2:00am.

Follow Up... What Did We Do?

So we decided to evacuate because.... A) Considering that we were supposed to stay in Boston until Saturday, we ran the risk of having our entire 10-person group contract the norovirus. We also risked giving the virus back to the vets who gave it to us at the shelter. People who had already had the virus, like Carter for example, could easily get sick again. I'm all for sharing, but the norovirus is NOT something you want to share. B) Considering that we were staying at the church, we ran a huge risk of spreading the virus to many other people including the children who use the rooms we were staying in, the Harvard students we shared the kitchen with, and the homeless population who used the same showers we used.We ended up wearing face masks to protect other people. This protection was more mental than physical, since the norovirus is transmitted via the fecal to oral route, not through airborne droplets. Although if I coughed after having just vomited, I could have spread the bug to my surrounding area. But hand washing was the main form of prevention and quarantining ourselves.Don't get me wrong, I thoroughly enjoyed the trip. I bonded with these strangers over the norovirus and community service. Within days of knowing each other we were cleaning up vomit and confessing of having shit our pants.... yes, it happened THRICE on the trip. I kid you not. I was lucky enough not to have any poopy pants, but out of the 5 of us, a couple of people did. We became instant friends and if given the opportunity to relive the experience, norovirus and all, I would be first on the sign up list. It's funny because I had a friend going on a cruise and I gave her such a hard time for not returning her ticket for a refund. I thought for sure she would get sick with the nrovirus.... touché universe, touché.So in conclusion, WASH YOUR HANDS, WASH YOUR HANDS, AND FOR GODS SAKE WASH YOUR HANDS!!!!! Also, never doubt your god given talents and abilities. I never thought I could puke and poop simultaneously, but boy was I very wrong. I am quite talented indeed. =)

About the author...

Dr. Anne Baber Wallis is a reproductive epidemiologist interested in social and biological causes of disease and an array of methodology and theoretical approaches to improve maternal health and neonatal outcomes globally. She has ongoing research projects based in Romania and India, and she collaborates with researchers elsewhere in eastern Europe and in The Gambia. Anne is a Fulbright specialist scholar and lives in Iowa City, with her husband, Matthew; her sons; any number of cats; a couple of dogs; and her horse, Beau. Anne is fascinated by nearly everything, loves riding (fox-hunting!), reading, and music from Bach to Mahler to Ligeti to Miles Davis, and Radiohead.